Introduction An intensive care unit (ICU), also sometimes known as a critical care unit or an intensive therapy department is a special

ward found inside most hospitals. It provides intensive care (treatment and monitoring) for people who are in a critically ill or unstable condition. Patients in ICUs need constant medical support to keep their body functions going. They may not be able to breathe on their own, and may have multiple organ failure, so medical equipment takes the place of these functions while they recover.There are several circumstances in which a person may be admitted to intensive care, for example, following surgery, or after an accident or severe illness. ICU beds are a very expensive and limited resource because they provide specialized monitoring equipment, a high degree of medical expertise and constant access to highly trained nurses (usually one nurse for each bed). Being in an ICU can be a daunting experience both for the patient and his or her friends and family. The healthcare professionals in ICUs understand this and are there to help and support both patients and their families during their time in intensive care. Myocardial infarction (MI) is the irreversible necrosis of heart muscle secondary to prolonged ischemia. This usually results from an imbalance of oxygen supply and demand. The appearance of cardiac enzymes in the circulation generally indicates myocardial necrosis. MI is considered, more appropriately, part of a spectrum referred to an acute coronary syndromes (ACSs), which also includes unstable angina and nonSTelevation MI (NSTEMI). Patients with ischemic discomfort may or may not have STsegment elevation. Most of those with ST-segment elevation will develop Q waves. Those without ST elevations will ultimately be diagnosed with unstable angina or NSTEMI based on the presence of cardiac enzymes. MI may lead to impairment of systolic function or diastolic function and to increased predisposition to arrhythmias and other long-term complications. Myocardial Infarction (MI) is one of the effects of the disease atherosclerosis. It is characterized by the destruction of a portion of myocardium caused by an interruption in blood flow resulting to the formation of localized necrotic areas. It is commonly known as coronary thrombosis, cardiac arrest or heart attack. Acute MI can cause permanent damaged of heart muscles as in thrombotic occlusion of a branch of an atherosclerotic

coronary artery. It is often accompanied by severe pain, shock, cardiac dysfunction and even death. This usually results from plaque rupture with thrombus formation in a coronary vessel,, resulting in acute reduction of blood supply to a portion of the myocardium. Atherosclerotic plaque formation involves many risk factors such as age, gender, smoking, inherited lipoprotein disorders, diabetes mellitus (DM), poorly controlled hypertension, type A personality, family history and having a sedentary lifestyle. Increasing age predisposes more risk factors in an individual which make that individual prone to cardiovascular diseases (CVDs). It is more common to males than females. Smoking tends to increase the incidence of MI due to the vasoconstrictor effect of nicotine or to some undesirable effects on the coagulability of the blood or the survival of the platelets. Hypertension may also cause MI since it is the persistent elevation of a systolic blood pressure above 140 mmHg and diastolic pressure above 90 mmHg. Other causes of MI are coronary artery vasospasm, ventricular hypertrophy, hypoxia due to CO poisoning or acute pulmonary disorders, coronary artery emboli, cocaine, ampethamines and ephedrine, and other coronary anomalies. A myocardial infarction can occur at any time of the day. This can be identified with observations of the following signs and symptoms:  Chest pain described as a pressure sensation, fullness, or squeezing in the midportion of the thorax.  Radiation of chest pain into the jaw or teeth, shoulder, arm and/or back  Associated with shortness of breath  Associated with epigastric discomfort which may or may not cause nausea or vomiting.  Associated with sweating Myocardial infarction can also be a cause of hyperlipoprotenemia type IV, which is an elevation of lipoprotein factors in the blood. It is characterized by an overproduction and impaired clearance of very low density lipoprotein (VLDL). This order may be hereditary or associated with diabetes mellitus or another metabolic disorder. Obesity and atherosclerosis are also frequent causes.

Overview of the Condition The patient was never ask a consultation at the Physician as long as he can stand alone and can walk. Until he woke up with vulnerable condition, the reason to seek a health management. He doesnt care, too much, what should be the food to be intake, and what not should be, too. He always telling his wife ano na lang ang kakainin ko?!. And now he is feeding thru NGT with low salt, low cholesterol and 1,800kCal. He used to commode at least once a day before he admit MICU, according to his wife. The physician ordered a Lactulose 30 cc to help him in bowel movement. The patient working as a carpenter, before his condition getting bad. At the MICU, helping the patient turning side-to-side every two hours, as ordered by the physician, and do the passive R.O.M. According to his wife, he sleep for almost 5-6 hour with irregular habit time of sleep. The patient had never awake, since he transferred at MICU. He perform self-care within the level of ability to do the ADL and other activity. Since he got an Intracerebral hemorrhage, he had disturbed perceptual abilities due to his illness. He took a healthy body for granted, a kind of denial of the eventuality of aging and illness. Due to the threats to self-concepts about the self these condition may pose. He was hard worker and good father to his family. Because of his condition, he is now lying at room # 5, MICU. His family involved in decision making processes directed at appropriate solution for the situation crisis. He had children by their own. Since, he got CAD, less frequency and satisfaction of their sexual activity. When the patient felt stress, he used to smoke. Although he know there is other way to move the stress away. They do visit their church together with their family aside from his son, working on weekends. All we know, Adventist should not eat pork, but he still doing it.

Demographic Data

Name: A.P.G

Age: 71 years old

Sex: Male

Address: 181 D. Silang St. Batangas City Birthday: October 2, 1937 Religion: 7TH Day Adventist Birthplace: Batangas Status: Married

Race: Filipino Admitted to E.R.: March 4, 2009, Chief Complaint: Right side body weakness Diagnosis: Nosocomial Pneumonia; CAD, ACS, NSTMI, Killip II, HCVD, FC II, Intracerebral he, (L) Basal Ganglia with intraventricular extension Transferred to M.I.C.U.: March 7, 2009 Room #: 5 Rank: C/V/T Health History 1. History of Present Illness The patient was not able to get up at early morning, as they notice. Then two hours he had vomited episodely and cramping, so, their relatives Santiago General Hospital. Then, they transferred at 10:00 AM. 2. Past Medical History He have a high blood pressure, not complaining for almost 10 years, he taking the drugs that given to him since the last consultation. 3. Family Medical History He had history of hypertension and diabetes mellitus on paternal side. 4. Social History According to his wife, he used to smoke 8-10 sticks per day but he occasionally drinks any liquor. He sleeps 5-6 hours a day, irregular habit time of sleep. only AFPMC after

rush up at Fort V.Luna, around

Genogram
Grandmother (Old age) Grandfather (hypertension) Grandmother (pneumonia) Grandfather (stroke)

Father (stroke)

Mother

APG

Physical Assessment: Head to Toe General Survey: Vital Signs BP 110/80 Temp. 37.4C RR - 40 PR 101 bpm

Unconscious patient lying on bed, with the position of semi-fowlers Integument Cold skin, from the body to lower extremity. The head, right and left arm are enough heat skin. Nails, delayed refill capillary Moist skin on his face and neck Head and neck Skull and face, shape symmetry Neck, no presence of contusions. Eyes, yellow conjunctiva, unequal pupil 2-3 mm pupil on left and 3-4 pupil on right Ears, lesion on auricle of the Left ear Nose, nasal flaring, placing an NGT (French 18) on his Left. Mouth, placing an Endotracheal tube with 7.0, plastering on his right lips; dry lips, yellowish teeth Chest RR- 40 auscultated chest with crackles sounds Extra sounds on Heart sounds Abdomen, no contour, no lesions Apical pulse rate: 101 bpm Extremity Left arm infused IV Fluid Right arm, no muscle tone, no strength muscle, +1 edema scale Left and Right leg, are pale, cold & dry skin, delayed capillary refill Genito Elimination Urine, yellow-orange, 200 cc at 4 hours. Bowel, no bowel movements

Neurological Glasgow Coma Scale: total score of 6 Eye: 2, he slightly his upper eyelid on pain Motor: 3, flexes abnormally Verbal: 1, no response Level of conciousness: comatose Diagnosis

Persistent chest pain, ST- segment changes on the electrocardiogram (ECG), and elevated levels of total creatinine kinase (CK) and the CK-MB isoenzyme over a 72 hour usually confirm an MI. Cardiac troponins are useful in differentiating an MI from skeletal muscle injury, or when CK-MB measurements are low and a small MI has actually occurred. Auscultation may reveal diminished heart sounds, gallops, and, in papillary dysfunction, the apical systolic murmur of mitral valve area. When signs and symptoms are equivocal, assume that the patient has had an MI until tests rule it out. Diagnostic test results include the following:  Serial 12-lead ECG: ECG abnormalities may be absent or inconclusive during first few hours following an MI. When present, characteristics abnormalities include serial ST-segment depression in subendocardial MI and ST-segment elevation in a transmural MI.  Coronary Angiography: visualization reveals which vessels have been affected and the extent of damage.  Serial serum enzyme levels: CK levels are elevated ; specifically, CK-MB or troponin levels.  Myoglobin: because myoglobin always rises within 3-6 hours after an MI, lack of an increase within 6 hours indicates that an MI hasnt occurred.  Echocardiography: may show ventricular-wall motion abnormalities in patients with a transmural MI.  Nuclear ventriculography (multigated acquisition scan or radionuclide

ventriculography) scanning: Nuclear scanning can identify acutely damaged

muscle by picking up radioactive nucleotide, which appears as a hot spot on the film. Its useful in localizing a recent MI.  Chest X-ray: venous congestion, cardiomegaly, and kerleys B lines  Cardiac catheterization: show decrease cardiac output, increase in Pulmonary arterial pressure, pulmonary artery wedge pressure and central venous pressure.  Auscultation: reveals holosystolic murmur and thrill. And also reveals a friction rub. ABG Analysis: reduced partial pressure of arterial oxygen. Hematology  Hematology: Hgb: still at normal ranges. Hct: acute massive blood loss RBC: decreasing due to side effects of the drugs. WBC: Increasing due to immunocompromised, immune responses. Platelet: increasing the fibrin that attract the platelet to increased Blood indices: MCHC: decreased in severe hypochromic anemia.  Coagulation: Bleeding time: defective in platelet function INR: prolonged in deficiency of fibrinogen; used to standardized prothrombin time and anti-coagulation therapy.  Serum enzyme levels: Na+ : decreased; myxedema K+ : decreased; GI losses, Vitamin D Deficiency Cl+ : decreased; pneumonia, febrile condition. Creatinine: decreased; check the status of the kidney Troponin: negative; if increased the patient may experience myocardial infarction. the

Pathophysiology

In an MI, an area of the myocardium is permanently destroyed; a condition in which the blood supply to the heart muscle is partially or completely blocked. The heart muscle needs a constant supply of oxygen-rich blood. The coronary arteries, which branch off the aorta just after it leaves the heart, deliver this blood. MI is usually caused by the reduced blood flow in a coronary artery of an atherosclerotic plaque and subsequent occlusion of the artery by a thrombus. Coronary artery disease can block blood flow, causing chest pain. In unstable angina and acute MI are considered to be the same process but different appoints along a continuum. specifically coronary atherosclerosis (literally hardening of the arteries, which involves fatty deposits in the artery walls and may progress to narrowing and even blockage of blood flow in the artery., As an atheroma grows, it may bulge into the artery, narrowing the interior (lumen) of the artery and partially blocking blood flow. With time, calcium accumulates in the atheroma. As an atheroma blocks more and more of a coronary artery, An atheroma, even one that is not blocking very much blood flow, may rupture suddenly. The rupture of an atheroma often triggers the formation of a blood clot (thrombus), the supply of oxygen-rich blood to the heart muscle (myocardium) can become inadequate. The blood supply is more likely to be inadequate during exertion, when the heart muscle requires more blood. An inadequate blood supply to the heart muscle (from any cause) is called myocardial ischemia. If the heart does not receive enough blood, it can no longer contract and pump blood normally. Other causes of MI include vasospasm, (sudden constriction or narrowing) of a coronary artery, decreased oxygen supply (e.g. from acute blood loss, anemia, or low blood pressure), and increased demand for oxygen (e.g. rapid heart rate, thyrotoxicosis, or ingestion of cocaine). In each case, a profound imbalance exists between myocardial oxygen supply and demand. The area of infarction develops over minutes to hours. As the cells are deprived of oxygen, ischemia develop, cellular injury occurs,, and the lack of oxygen results in infarction, or the death of cells. The area of the heart muscle supplied by the blocked artery dies.

General Analysis

Activity intolerance imbalance between myocardial oxygen supply/demand.

 Grieving, anticipatoryperceived loss of general well-being, required changes in lifestyle, confronting mortality.  Decisional Conflict (treatment)multiple/divergent sources of information, perceived threat to value system, support system deficit.  Family Processes, interruptedsituational transition and crisis.  Home Management, impairedaltered ability to perform tasks, inadequate support systems, reluctance to request assistance. Medications Promotes adherence measures by thoroughly explaining the prescribed medication regimen and other treatment measures. Warn the patients together with relatives about adverse reaction to drugs, and advise them to watch the sign and symptoms of toxic (nausea, anorexia, vomiting, and yellow vision) Exercises Organize patient care and activities to maximize periods of uninterrupted rest. Assist with range-of-motion exercise. And turn him, every two hours, as ordered by physician. Dont stress yourself, too much exercise. Enough, walk for 15 minutes. Treatment Antiembolism stockings help prevent venostasis and thromboplebitis. Encourage participation in a cardiac rehabilitation program.

Aesthetic way/ Art of Care The health care provider follows nursing guidelines for the MI patients. Document level of activity attempted and tolerance. Nurisng is responsible for documenting whether expected outcomes are met or not met. The patient has performed activities of daily living with no angina symptoms for the last 24 hours when he was admitted. While the vital signs have been within patients norm for the last 24 hours. Ethical-moral Nurse judgment on what must to be done during health care to reach the goal of care without unethical behavior. The presence of moral and ethical dilemma with the

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patient themselves and their family can contribute to the enhancement and recovery of the patient. Ethical Behavior of the nurses and their sensitivity of the patients right and availability. It is the responsibility of the nurse to claim the patients optimum care. Legal Interaction/Implications in the care Length of stay in the hospital and reason for failure to discharge at an early time is caused by thorough assessment of the patients performance and cope up with the nursing care management. Informed consent during management of the disease and illness, and other activities related to health care.

Synthesis and Conclusion

Case studies are based upon the real cases that are quite commonly encountered in the everyday practice of nursing and allied profession. Case studies are done to have the knowledge regarding different illness. In this case study, it describe the critical care as a collaborative, holistic approach that includes the patient, family and significant others. It established priority critical measures instituted for any patient with a critical condition. Almost all MIs are caused by rupture of coronary atherosclerotic plaques with superimposed coronary thrombosis. Patients with MI usually present with signs and symptoms of crushing chest pressure, diaphoresis, malignant ventricular arrhythmias, heart failure (HF), or shock. MI may also manifest itself as sudden cardiac death, which may not be apparent on autopsy (because necrosis takes time to develop). Presentations may be atypical and clinically subtle, especially in women. Findings may include new-onset or accelerated angina; atypical chest discomfort or abdominal discomfort mimicking indigestion; decreased cerebral perfusion with syncope; dizziness; cerebrovascular accident; altered mental status; or nausea and fatigue without chest pain. Evidence suggests a benefit from the use of beta blockers, angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARB), and possibly from insulin infusion (with potassium and glucose) to inhibit apoptosis (cell death). New

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therapies will provide some incremental gains. Greater gains may be improved with improved systems of care.